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SAN JOAQUIN COUNTY PUBLIC HEALTH SaRVICES <br /> :.JVIRONMENTAL HEALTH DIVISI(, W <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE. <br /> 12 REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACTPHONE# (209)466-6927 <br /> FACILITYNAMECalifornia Traction Company PHCNE# (209)466- 9 <br /> ADDRESS 1645 Cherokee Rd. , Stockton , CA 93205 <br /> CROSSSTREET San uinetti Ln. <br /> OWNEROPERATCR Central California Traction company PHCNE;*(209)466-6927 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Jim orpe Oil , Inc. PHONE* (209)368-6175 <br /> CONTRACTOR ADDRESS OY b CA LIC# 495699 CLASSA $ HAZ <br /> INSURER emper en ar WORKERCOMP# 1095135 <br /> FIRE DISTRICT PERMIT# upon approval <br /> LABORATORYNAME GeoAnal tical Labor at or1EWUNTY Stan I PHONE# <br /> SAMPLING FIRM GeoAnal tical LabOratOrieS I PHONE It <br /> TANK INFORMATION <br /> TANK Io X TANK SIZE TANK CGNTcNTS(PRESENT 3 PAST) DATE INSTALLS'^, <br /> 39- - <br /> 39- — 1,000 gal Diesel Fuel uk <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS. FEDERAL LAWS.AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUSUC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLCWING: 'I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A.MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE-ER7IF;E3 <br /> THE FOLLOWING: 'I CERTIFY THAT IN TH ERFCRMANCE CF THE W K FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUS_E-_T 0 <br /> WORKER'S COMPENSATION:AMCFRNIA.* <br /> APPLICANTS SIGNATURE ITL= (contractor DA7El9 /ll /QR <br /> ❑ APPROVED VAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> /,, (SEE CCNCITICNS BELOW ANCIOR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME:-- LG. OAT=- <br /> ANY DEVIATICNS FROM THIS APPLICATION MUST BE SUBMITTED TO END FOR APPROVAL PRIOR TO COMMENCING WCRK. <br /> CONDITIONS: <br /> I <br /> EH 23 046 REVISED 10119198) Page 3 <br />